CC
A 21-year-old female presents with complaints of “I don’t like my gummy smile and weak chin.”
HPI
The patient has a skeletal and dental class II malocclusion with mandibular hypoplasia, maxillary vertical excess, microgenia with a convex facial profile, and a steep mandibular plane angle. She was referred by her orthodontist for maxillary and mandibular orthognathic surgery in conjunction with comprehensive orthodontic treatment. She has been in active orthodontic therapy for 9 months and is ready for the surgical phase of treatment. The patient has presented to all appointments with her mother, who will be the caretaker after surgery. Both the patient and her mother are attentive and interested in the surgery and ask appropriate questions.
PMHX/PDHX/medications/allergies/SH/FH
The patient’s past medical history is noncontributory. She has been wearing an orthodontic appliances for 9 months; this is her second time to have orthodontic treatment. She had her tonsils removed at 13 years of age, after which she experienced postoperative nausea and vomiting (PONV). She does not use any medications and denies any drug allergies. She denies tobacco use or any other drug or alcohol use.
Examination
General. Well-developed and well-nourished female with normal and mature affect.
Weight. She weighs 65 kg.
Vital signs. Vital signs are normal and the patient is afebrile.
Maxillofacial. Normocephalic. No lymphadenopathy. Examination of the temporomandibular joint reveals no clicking, popping, or pain upon palpation. The muscles of mastication are nontender to palpation. Cranial nerves are normal bilaterally. Deficiency of infraorbital and malar regions. Excessive anterior and posterior gingival display on animation. Lip incompetence at rest approximately 4 to 5 mm. Long lower facial third. Mentalis strain is present. Mandibular midline is on midsagittal plane. Poor genial projection. Convex facial profile.
Intraoral. The maxillary and mandibular dental midlines are coincident with the midsagittal plane. Overbite is 60%, and overjet is 5 mm. Maxillary and mandibular arches are ovoid. The third molars are not visible intraorally. Orthodontic brackets in place with bands on all molars; surgical wire is present with surgical lugs. Good oral hygiene and no periodontal disease. No soft tissue lesions, swellings, or signs of infection.
Airway. Maximum interincisal opening 3+ fingerbreadths, Mallampati class I, thyromental distance 2 fingerbreadths.
Cardiovascular. Heart has a regular rate and rhythm.
Pulmonary. Lungs are clear to auscultation bilaterally.
Imaging
Panoramic and lateral cephalometric radiographs were taken at her initial evaluation. A cone-beam computed tomography scan was taken for virtual surgical planning.
Labs
Basic metabolic and coagulation panels were obtained preoperatively and were within normal limits. A quantitative human chorionic gonadotropin urine test was ordered for the day of her surgery.
Assessment
This is a 21-year-old female with skeletal and dental class II malocclusion secondary to her mandibular hypoplasia, maxillary vertical excess, and with microgenia.
Treatment
The plan for this patient is a Le Fort I single-piece maxillary osteotomy, bilateral sagittal split mandibular osteotomy, and genioplasty with general anesthesia in a hospital operating room setting using an early recovery after surgery (ERAS) protocol. The protocol is implemented by a multidisciplinary team approach. In head and neck major surgery, this team often includes surgeon and office staff, anesthesia, nursing (postanesthesia care unit [PACU], intensive care unit [ICU], or surgical ward), nutritionist, speech-language pathologist, and physical therapy. A surgical service using an ERAS protocol must have cooperation and participation by all team members for every perioperative phase.
The following protocol was used for this patient:
- 1.
Patient and caregiver education
- a.
Patient surgical education included nutritional needs and preparation, pain expectations and management, use of and directions for medications, oral care and wound care instructions, activity restrictions, and expected postoperative course.
- b.
Caregiver is included in all discussions.
- c.
Postoperative medications are ordered and dispensed before surgery if possible.
- d.
Nutrition consultation is optional for management of a nonchew diet.
- a.
- 2.
Preoperative fasting guidelines and carbohydrate loading
- a.
Light meal at 6 hours before surgery, clear fluids up to 2 hours before surgery, avoid 8+ hours of fasting
- b.
Complex carbohydrate clear drink with 30-g to 50-g complex carbohydrates: 1 drink the night before surgery, 1 drink 2 hours before surgery
- a.
- 3.
Preoperative medications
- a.
Acetaminophen 500 to 1000 mg
- b.
Gabapentin 300 mg
- c.
Nonsteroidal antiinflammatory drug (NSAID) (ketorolac 15–30 mg, ibuprofen 600–800 mg, or meloxicam 30 mg)
- d.
Scopolamine transdermal patch and/or aprepitant 40 mg
- a.
- 4.
Anesthetic management
- a.
Multimodal induction and maintenance, opioid sparing (propofol, lidocaine, dexmedetomidine, volatile anesthetics)
- b.
Short-acting opioids only: fentanyl 0.5 to 2 mcg/kg; avoid long-acting opioids such as hydromorphone and morphine
- c.
Video-assisted laryngoscopy for atraumatic intubation
- d.
Nondepolarizing neuromuscular blockade
- e.
Ondansetron 4 mg
- f.
Dexamethasone 8 to 10 mg
- g.
General fluid restriction to less than 1 L
- h.
Avoid intraoperative hypothermia
- i.
Remove Foley catheter before emergence, if used
- a.
- 5.
Surgical management
- a.
Prophylactic antibiotic for clean-contaminated case; continue for 24 hours
- b.
Minimally invasive, if possible
- c.
Use local anesthesia: 1% to 2% lidocaine infiltration before incisions
- d.
Use of virtual surgical planning and/or custom hardware and splints for accuracy and decreased operating time
- e.
Light dental elastics only, if possible
- f.
Antifibrinolytic: tranexamic acid 1g
- g.
Long-acting local anesthesia: 0.25% to 0.5% bupivacaine or liposomal bupivacaine (10–20 mL) at the end of the procedure
- a.
- 6.
PACU considerations
- a.
Oral medications for analgesia when tolerated: acetaminophen/hydrocodone liquid or tablets, NSAID liquid or tablets
- b.
Short-acting opioids (fentanyl 25–50 mcg ×2) for breakthrough/severe pain only
- c.
Aggressively treat nausea or vomiting; use nonsedative antiemetics such as ondansetron or metoclopramide
- d.
Head of bed up at 45 degrees
- e.
Face tent or mask, humidified: wean to room air as soon as possible
- f.
Minimal suctioning, ice to face
- g.
Encourage early oral intake of fluids
- h.
Encourage early ambulation
- a.
- 7.
Postoperative medications
- a.
Acetaminophen and NSAIDs scheduled for 5 to 7 days
- b.
Opioids: hydrocodone or oxycodone for moderate to severe pain
- c.
Chlorhexidine oral rinse
- d.
Nasal saline rinse, decongestant as needed
- a.
- 8.
Discharge considerations
- a.
Instructions for continued ambulation; oral fluid and nutritional intake; wound, oral, and nasal care instructions; activity limitations; deep breathing exercises; and sinus precautions if applicable
- b.
Scheduled interval follow-up appointments
- a.
Complications
The ERAS protocol was implemented by all multidiscipline team members, and the surgery was completed without intra- or postoperative complications. After her initial emergence and recovery period in the PACU, the patient was able to tolerate oral medications and oral liquid intake. Her pain was well controlled with oral medications. She ambulated early with assistance, voided before discharge, and had no nausea or vomiting. She was alert and oriented and had a positive outlook. Her vital signs were stable, and she was on humidified room air only; there were no supplemental oxygen requirements. There were no bleeding or airway concerns at her evaluation before discharge. She was discharged from the hospital on the same day, in the evening, with a scheduled 24-hour follow up phone call and office visit if needed, and 1- and 3-week follow-up appointments with the surgeon.
Orthognathic surgery has become widely accepted for correction of dentofacial deformities. With modifications over several years to the surgical and anesthetic techniques to minimize operating time, blood loss, fluid overload and edema, and nausea and vomiting; optimize pain control; and eliminate the need for maxillomandibular fixation, it is widely accepted that patients undergoing single-jaw surgeries are able to be discharged the same day and that those undergoing double-jaw surgeries likely only require a single night stay, often with a less than 24-hour discharge. Implementing ERAS protocols to major oral and maxillofacial surgeries such as orthognathic surgery or even head and neck reconstructive surgeries has the following goals: decrease length of hospital stay, reduce readmissions and emergency department visits, minimize surgical or postoperative complications, and minimize the physiologic stress or strain imposed on the body’s systems by a major surgical procedure and its required anesthesia. The secondary gains of these goals are decreased health care costs, decreased morbidity, and increased patient satisfaction.
Discussion
Eras in oral and maxillofacial surgery
ERAS protocols are intended for major surgeries and have been studied in many different surgical specialties. There is no evidence for the implementation of these protocols to minor surgical procedures or office-based procedures. Many oral and maxillofacial surgeons are currently using components of the proposed ERAS protocols available in the literature and applying them to major and minor surgeries routinely. To truly use an ERAS protocol, there must be organizational change, education at all levels, and buy-in and participation by the entire perioperative team.
The ERAS concept was first proposed and published by Dr. Henrik Kehlet in the 1990s as a multimodal approach to perioperative patient care to combat the pathophysiologic stress brought on by surgery and its complications. This idea led to the formation of a group in the early 2000s that was committed to researching the best practice for this multimodal perioperative care. The goal of this group was to examine ways to improve perioperative care and enhance postoperative recovery by implementing evidence-based practice, audit, education, and research. This ERAS group reevaluated the traditional methods of perioperative care to create a process to shorten hospital stays, reduce complications, reduce readmissions, and improve patient satisfaction. The ERAS Society was founded in 2010 and has published its studies for many surgical specialties and specific surgery types. To date, the only ERAS protocol publication from this society which applies to the oral and maxillofacial surgery (OMS) specialty is for head and neck reconstructive surgery in the recommendations published by Dort et al. (2017). There have been very few prospective and retrospective studies published that address orthognathic surgery and the authors’ institutional ERAS protocols. These studies have different outcome measures, and no standard has been published for this type of surgery because of a lack of consistent evidence for perioperative care methods for this specific surgical subset. It would be impossible and impractical to apply a single ERAS protocol to all surgical procedures, which is why the need for more prospective, blinded studies are needed to apply specifically to the needs of OMS patients.
The ERAS protocol for head and neck cancer surgery from the ERAS Society suggests 17 elements of intervention, with 24 recommendations for optimal perioperative care, the majority rated as having moderate to strong levels of evidence. The authors admit that some of the recommendations have been extrapolated from research in other surgical specialties. These extensive guidelines may not, or cannot, be realistically implemented in some institutions or may not even apply to all major head and neck cases. Therefore, there is a continued need for simplification and recognition of the core components of each ERAS protocol so they may be more universally applied to OMS patients. Some of these core components are improved patient education, minimally invasive surgery, goal-directed fluid therapy, multimodal opioid-sparing analgesia, early oral feeding, and early mobilization. The components of the ERAS protocol used in this case example are discussed in detail later in this chapter and were created from existing publications on orthognathic perioperative care, the ERAS Society publication, and other protocols from varying specialties in the literature.
Evidence-based eras elements
Preadmission education
Preparing patients and families for major surgery is believed to be worthwhile by surgeons and patients. Unfortunately, there is limited evidence to demonstrate that patient education has a beneficial effect on patient outcomes. In the context of the biobehavioral model of stress, patient education may decrease the physiologic effects of stress in the perioperative period, and stress can negatively affect wound healing and complications. Patients and caregivers who are educated and prepared will likely have less anxiety about the process and be more compliant in the perioperative period. In this case review, the patient was educated on topics that included the surgery, postoperative course expectations, pain expectations and management, diet, activity, oral and wound care, and how to use her postoperative medications. Her caregiver was present for all education.
Perioperative nutritional care
This is a complex topic for head and neck cancer patients because many patients may have preoperative malnutrition, existing dysphasia, or mechanical obstruction. Screening for malnutrition and preoperatively optimizing nutritional status are recommended. This recommendation is based on the existing nutritional care guidelines for patients with head and neck cancers. Orthognathic patients have a significant diet change in the postoperative period and may need counseling on dietary needs and caloric intake on a nonchew diet. It is recommended that patients minimize preoperative fasting and dehydration and implement complex carbohydrate loading preoperatively followed by early oral intake. This is a component of many ERAS protocols, but the evidence specifically for head and neck patients is limited. It is therefore extrapolated from protocols involving studies of nutritional care in other types of cancer. Preoperative carbohydrate loading arises from the hypothesis that these fluids help mitigate insulin resistance and catabolism brought on by fasting and surgical stress, promoting better glucose control and lean tissue preservation. Unfortunately, well-designed trials to support this claim are lacking and needed for the head and neck surgical population. When to reintroduce oral feeding in a patient with head and neck cancer can be a complex decision and should involve the consultation with the surgeon, speech-language pathologist, and nutritionist. In this case review, the patient was asked to intake clear fluids up to 2 hours before her surgery and drink a complex carbohydrate clear drink (e.g., Ensure Pre-Surgery Clear Carbohydrate Drink or Clear Fast CF Preop Drink) the night before surgery and 2 hours before surgery. She was counseled on a nonchew diet, and a nutrition consultation was optional.
Antibiotic prophylaxis
Perioperative antibiotics, given 1 to 2 hours before surgery and continued for 24 hours, have consistently demonstrated a significant reduction in wound infections in randomized controlled trials. It is therefore standard of care for clean-contaminated head and neck surgical procedures and recommended in most ERAS protocols.
Postoperative nausea and vomiting prophylaxis
Postoperative nausea and vomiting prophylaxis should be considered for all patients undergoing oral and maxillofacial surgeries because they are at moderate to high risk. Vomiting can cause wound dehiscence, hematoma, and wound infection, and nausea and vomiting can inhibit early ambulation. The combination of ondansetron and dexamethasone has been proven efficacious and is recommended in head and neck surgery ERAS protocols. Rescue antiemetics should be used early if needed, and a different drug class should be considered while avoiding sedative medications such as promethazine. In this case review, the patient was given a preoperative scopolamine transdermal patch and intraoperative ondansetron and dexamethasone to combat PONV.
Preanesthetic medications
According to the ERAS Society publication, data shows that the prevalence of preoperative anxiety is up to 80%. Nonpharmacologic interventions can be used; also the use of short-acting benzodiazepines has been proven effective in relief of preoperative anxiety. The goal of use of these tactics or medications is to contribute to the overall ERAS goal of decreased physiologic stress, which is closely linked to psychological stress. In this case review, the patient did not have preoperative anxiety because of extensive preoperative education and counseling, and she was well hydrated and was not in a fasting state because of her carbohydrate drink. She was given other preanesthetic medications to contribute to her overall multimodal anesthetic and analgesic approach, to include acetaminophen, gabapentin, and an NSAID. This methodology was taken from a study that included these medications in their institution’s ERAS protocol for orthognathic surgery that demonstrated shorter hospital stays and decreased opioid demand. Other studies have shown that preoperative use of acetaminophen and gabapentin resulted in decreased postoperative pain scale scores.
Standard anesthetic protocol
The general anesthetic principles for ERAS protocols are the following: perioperative rehabilitation or medical optimization, perioperative nutrition, carbohydrate loading, prevention and treatment of PONV, aggressive intraoperative warming, prophylactic antibiotic administration, use of opioid-sparing multimodal anesthesia techniques, fluid management, and lung-protective ventilation strategies. ERAS protocols do not suggest the use of any specific type of regimen to maintain unconsciousness during surgery. In fact, the current literature is silent on this topic. In general, ERAS protocols recommend collaboration with the anesthesia team to establish the anesthetic protocol for specific surgeries.
Preventing hypothermia
Hypothermia is associated with poor surgical outcomes, including adverse cardiac events, wound infection, and bleeding. Intraoperative hypothermia may also affect graft patency in head and neck reconstruction, affect drug pharmacokinetics, and interfere with normal coagulation. Postoperative shivering thermogenesis increases metabolic rate and oxygen consumption. One study showed an increase in length of PACU stay and length of hospital stay, therefore increasing costs for patients who experienced perioperative hypothermia. Intraoperative normothermia has been established as an evidence-based key element to ERAS protocols.
Perioperative fluid management
Most ERAS protocols aim for a net-zero fluid balance during the perioperative period. This strategy is also referred to as goal-directed fluid therapy (GDFT). The GDFT technique has shown a statistically significant decrease in ICU stays and length of hospital stays in patients undergoing high-risk surgeries and does not affect morbidity. The evidence for this recommendation was moderate, but it is a strong recommendation by the ERAS Society studies in most protocols. It is recommended to use balanced fluids and avoid normal saline. Minimal maintenance fluids are recommended, and fluid boluses are used to treat objective hypovolemia. Vasoactive drugs and blood products should be used judiciously. In this case review, it was also recommended that no more than 1 L of intraoperative fluids be used, if possible, to reduce surgical site edema.
Pain management
This element has been thoroughly studied in many surgical specialties and in head and neck surgery. Postoperatively, multimodal analgesia through the use of acetaminophen, local anesthetic wound infiltration, NSAIDs, gabapentin, and short-acting opioids effectively treats pain, facilitates rapid recovery, and minimizes the doses of opioids used and their associated adverse effects such as sedation, PONV, pruritis, and ileus. The level of evidence for this recommendation is high and is present in most ERAS protocols.
Postoperative mobilization
Most data on early mobilization are from patients undergoing major abdominal procedures, which showed that early mobilization, as part of a comprehensive treatment protocol, reduced complications and overall length of hospital stay. A secondary analysis of the randomized Laparoscopy in Combination with Fast Track Multimodal Management (LAFA) study showed that early mobilization was a significant independent predictor of a good outcome. The data for head and neck surgery specifically is limited; therefore, the recommendation is based on evidence from other types of surgeries. In this case review, the patient was encouraged by PACU nurses to ambulate early on the same day as her surgery before discharge.
The components from the ERAS Society’s evidence-based topics for head and neck cancer surgery that were not used in this orthognathic case review are ICU admissions, tracheostomy care, prophylaxis against thromboembolism, urinary catheterization, postoperative flap monitoring, postoperative wound care, and postoperative pulmonary physical therapy. These are examples of protocol components that are critical for a head and neck cancer reconstruction with a free flap but do not necessarily apply to orthognathic surgery patients. All 17 elements and 24 recommendations can be reviewed in the original publication cited in the Bibliography.
Implementation of protocol and future studies
Most ERAS outcome measures have focused on patient length of stay, complication rates, readmission, and overall cost of hospital stay. In 2017, Lau et al. published a meta-analysis on 42 randomized clinical trials involving ERAS protocols across multiple specialties. They showed that ERAS programs provided a significant reduction in length of stay of 2.35 days compared with standard care methods. This finding was confirmed by a study by Visioni et al. in 2018. Both the Lau and Visioni studies also demonstrated a statistically significant reduction in the risk of postoperative complications between the ERAS and control groups. They demonstrated no statistical difference in readmissions between the ERAS and control groups.
Elements of existing ERAS protocols can be applied to major oral and maxillofacial surgical procedures to include head and neck cancer reconstruction and orthognathic surgery, as demonstrated in some recent studies and in this case example. But the evidence specific to this specialty and these surgeries is lacking and must be extrapolated from other surgical specialties to create protocols that fit our patients. Future high-quality studies of these protocols in our field would ensure the acceptance of evidence-based practice for ERAS protocols in major oral and maxillofacial surgeries.
Bibliography
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